Provider Demographics
NPI:1275732398
Name:COSTON, ROGER ALTON (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:ALTON
Last Name:COSTON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 BROWN TRL STE 2
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76021-4182
Mailing Address - Country:US
Mailing Address - Phone:817-280-0788
Mailing Address - Fax:817-280-9652
Practice Address - Street 1:2700 BROWN TRL STE 2
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-4182
Practice Address - Country:US
Practice Address - Phone:817-280-0788
Practice Address - Fax:817-280-9652
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX16820122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist